89284A - Horton, Don

°"°""❑CAMA ❑DREDGE & FILL N0 89284 A B C D
GENERAL PERMIT Previous permit
Date previous permit issued
❑New ❑Modification []Complete Reissue []Partial Reissue
As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to:
15A NCAC ❑ Rules attached. ❑" General Permit Rules available at the following link: www.deq.nc.gov1CAMArules
Applicant Name
City
Phone # (< )
Email i .
ZIP
Authorized Agent i
Project Location (County):
Street Address/State Road/Lot #(s) j y�
Subdivision
City `,.
i < /
Affected ❑ CW Elm ❑ PTA ❑ ES ❑ FTS Adj. Wtr. Body nathhan/unk)
AEC(s): ❑OEA ❑IHA ❑uW ❑SPIMA ❑PWS Closest Maj. Wtr. Body
ORW: yes/no. PNA: yes/no
Type of Project/ Activity
(Stele: /v
MISS
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MEN
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MPJN
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MEMO
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CGS
SEES
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OWN
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A building permit/zoning permit may be required by:
Permit Conditions
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❑ TAR/PAM/NEUSE/BUFFER (circle one)
❑ See note on back regarding River Basin rules
❑ See additional notes/conditions on back
I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial)
li
Agent or Applicant PRINTED Name Permit Officer's PRINTED Name
Signature **Please read compliance statement on backof permit**
7(oS
Application Feels) Check q/Money Order
Signature I /y� / �S
// 2 /
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:t I Di TU ,-\
Mailing Address: 10 q 4y e�
cut-�Cr-' Vic
Phone Number: — — S-3 0 t)
Email Address: AM,4
I certify that I have authorized Let ak, /)lair- t^G/ L
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
R e co', Sir f:ck
11
at my property located at J d L't CL� �
in CGId l County.
I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
Signature
Print or Type Name
/ IWO
t
Date to
This certification is valid through i ( I
k

N.C. DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERY
(Top portion to beby owner or their agent)
completed
Uor4olx
Name of Property Owner.
a YlryciVCw'R��
Address of Property:
Mailing Address of Owner.
- aoa- 530 0
Owner's email: n�A' Owners Phone#: I;
Agent's Name: L !1 eel / 141rS /►e,-rAf- Agent Phone#: ase�' 331 ` �3 �3
L4iil4c e*-Vnep-S A e P b6 h41G1115 • CO /K
Agent's Email:
ADJACENT RIPARIAN PROPERTY OWNER'S CERTIFICATION
@242M-11001-
COMPLETE THIS SECTION ON I4*1
I hereby certify that I own ecC21=01-1 .
' '
DELIVERY
permit has described to me, a. - Comp' - s 1, 2, and 3. A. sign
❑Agent
description or drawing,with din s Print y:,,.. nd address on the'revarse X
❑ Addressee
so that we can Ic. 1he card to you.
I DO NOT have obje Attach this card to the ,jack of the mailpiece, S. Rejc�rved b (Prinse`�l Na e) C. Date of Delivery
)r on the front if space permits.
if you have objections to wl 1. Article Addressed to: D. Is delivery address different from item lT ❑Yes
If YES, enter delivery address below: ❑ No
Management (DGM) in writin; ��®L! �rt
s ko e be r 7
matted to 401 S. Griffin St..:
contacted at(252)2643901. a0rw Sptintat/
notifred by Certified Mail.
sox3
Pto.
1 ♦95
I understand that any proposeC. ��' ^ C e- +; �� a 3!/
3. Service Type
❑ Priority Mall Express®
groin must be set back a minm ii ❑ Adult Signature
(this does not apply to bulkheal IIIIIII'I I'll ICI IIIIII llll I II II llI II II IIIII III D Certf ed Mail® Restricted Delivery
❑ Registered Mall*"'
❑ Deelivery Mall Restricted
the appropriate blank below.) 9590 9402 8750 3310 1137 52 ❑ Certified Mail Restricted Delivery
❑ Collect on ni,s—c,
❑ Signature Confirmatloh*^t+
7 Signature Confirmation
-
Restricted Delivery
i DO wish to waive someiall of
Poo-vcv k auao
Domestic Return Receipt
I do not wish to waive the 15' setback requirement (initial the blank) < —
�-
Signature of Adjacent Riparian Property Owner (
TypedlPrinted name of ARPO: /7 /r r r' 5. koi `'r
Mailing Address ofARPO: P') PLOW
ARPO's email:
Date:
ARPO's Phone#:
"waiver is valid for up to one year from ARPO's Signature*
L-C4&1(en i'hurme ,rnc-
tic I)gJ06
Revised July 2021

IU.C. i aRSION OF COASTAL MANAGEMENT
CERTIFIED MAIL RETiIRN RECEIPT REQ ESTED orlHA�iDAIVER ��
DELIVERY
(Top portion to be completed by owner or their agent)
Name of Property owner oDo hn pD t4D ^ d
Address of ProPerey C���` --
Mailing Address of Owner
owner's email: /i�i9 Owner s Phoned J �� /
I ri /lad Agent Phoned2s a' 33l
Agent's Name: to �/�B�'IM�
Agents Email: a r r "" — - `
ADJACENT RIPARIAN PROPERTY OWMER'S CER 1 IFICA T iON
Bottom portion to be completed by the Adjacent Property Owner
I hereby certify that i own property adjacent to the above relam ed Prope,-ty_Yhe individual applying forthis
permit has described to me, as shown on the attached drawing, the development they are proposing- A
..,..ct fir nmvided w[ih ffirs letter.
This Proposal ! DO have objections to This proposal.
Ve I DO NOT have objections to T
It you have objections to what is befag propose You rnusf notiry the IN.G. Division of Coastal
Manageiment ruG" irr writing vvi& n tit nays of recdFf
ctbFs notir Correspondence should be
rnaiW to 401 S. Gsarrn S`., SIG 300, r:11M reth cW, NC; 27918f3GM rePreseTdatives can also be
contacted at (2M 264-39011. NO response is corrsidered the same as no obje_'ffon if you have been
nofifred by Certified Mail-
VJAIVER SECTION
I understand that any Proposed Pier, dock, mooring Pings, boat ramp, breakwater, boathouse, lift, or
groin must be set back a minimum distance of 15' from my area of riparian access unless waived by me
(#his does not apply to bulkheads or dPrap revelments)_ (tf you wish to waive the setback, you must stare
the appropriate blank below-)
I DO wish to waive samelall of the #5 s�o j
Signature of Adjacent Riparian roperty Ovmer
-OR-
I do not wish to waive the 1 5 setback requirement (initial the blank)
Signature of Adjacent Riparian Property Owner.
3ypediPrinted name of ARPO:
IV'lailing Address of ARPO:
ARPO's email: ARPO's Phone#3:
;;rate: 'waiver is valid for up to one year from ARPO's Signature
Revised July 2021

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